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Multiple Fractures With Pseudoaneurysm Formation in a Subclavian Artery Stent

2011; Lippincott Williams & Wilkins; Volume: 123; Issue: 20 Linguagem: Inglês

10.1161/circulationaha.110.015834

1524-4539

Ravi S. Math, Ravindranath Khandenahally Shankarappa, Ramesh Dwarakaprasad, Satish Karur, Shivakumar Bhairappa, Praveen Jayan, Cholenahally Nanjappa Manjunath,

Intracranial Aneurysms: Treatment and Complications

HomeCirculationVol. 123, No. 20Multiple Fractures With Pseudoaneurysm Formation in a Subclavian Artery Stent Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBMultiple Fractures With Pseudoaneurysm Formation in a Subclavian Artery Stent Ravi S. Math, Ravindranath Khandenahally Shankarappa, Ramesh Dwarakaprasad, Satish Karur, Shivakumar Bhairappa, Praveen Jayan J.P. and Cholenahally Nanjappa Manjunath Ravi S. MathRavi S. Math From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. , Ravindranath Khandenahally ShankarappaRavindranath Khandenahally Shankarappa From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. , Ramesh DwarakaprasadRamesh Dwarakaprasad From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. , Satish KarurSatish Karur From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. , Shivakumar BhairappaShivakumar Bhairappa From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. , Praveen Jayan J.P.Praveen Jayan J.P. From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. and Cholenahally Nanjappa ManjunathCholenahally Nanjappa Manjunath From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. Originally published24 May 2011https://doi.org/10.1161/CIRCULATIONAHA.110.015834Circulation. 2011;123:e602–e604A 50-year-old right-handed man (ex-smoker) with a history of left upper limb claudication for the previous 6 years underwent successful left subclavian artery (LSA) angioplasty with stent implantation (8×59 Genesis Stent [Cordis, Warren, NJ]) for 99% ostial and proximal stenosis of the LSA with use of a combined anterograde and retrograde approach (Figure 1A through 1D). The erythrocyte sedimentation rate and the C-reactive protein were normal. No other vascular system was affected. After an asymptomatic period of 4 months, the patient presented with a history of high-grade fever for 7 days, pain and swelling of the left hand, bluish discoloration of finger tips and palms, and restriction of movements of the fingers of left hand (Figure 2A). All left upper limb pulses were well felt. A Doppler arterial study of the left upper limb was also normal. At the diagnostic angiogram, fluoroscopy revealed that the LSA stent had transected at multiple levels (4 levels) (Figure 3A and Movie I of the online-only Data Supplement). The angiogram revealed the presence of 2 pseudoaneurysms, one at the origin of the LSA and another within the distal portion of the stent (Figure 3B and Movie II of the online-only Data Supplement). Flow within the stent and in the distal portion of the LSA and the brachial artery was normal. The stent fracture at multiple levels had led to pseudoaneurysm formation, thrombosis, and microembolization, thereby explaining the symptoms of the left hand. Three blood cultures taken from the left upper limb were reported as sterile. A 64-slice contrast-enhanced computed tomography of the chest ruled out stent compression by the thoracic structures (Figure 4A through 4D). It also revealed that there were 2 pseudoaneurysms (not 1, as earlier thought) at the origin of the LSA (Figure 4D). A 8×59 ADVANTA V12 covered stent (Atrium Medical Corp, Hudson, NH) was deployed across the previous LSA stent to cover the stent fractures and exclude the proximal and distal pseudoaneurysms. A repeat angiogram revealed that the distal pseudoaneurysm was successfully excluded, but flow in the proximal pseudoaneurysms was still present (Figure 5A). Flaring of the proximal end of the stent graft with a 9×10 ATB balloon at 12 atm to achieve a more optimal apposition did not exclude the flow. Finally, using a 6F right Judkins diagnostic catheter, 3 coils (two 0.038×8×8 Cook Embolization coils and one 0.038×5×4 Cook detachable coil; Cook Medical, Bloomington, IN) were deployed in the more anterior of the 2 proximal pseudoaneurysms, and 1 coil was deployed in the more posterior one (0.038×8×8 Cook Embolization coil) (Figure 5C and 5D), achieving complete occlusion. The pain, swelling, and discoloration improved dramatically (Figure 2B). Following a 2-week antibiotic course, the patient was discharged on dual antiplatelet (aspirin and clopidogrel) therapy. A check angiogram after 6 weeks (Movie III of the online-only Data Supplement) and a computed tomography angiogram after 12 weeks (Figure 6) confirmed stent-graft patency without evidence of fracture or pseudoaneurysm formation. At 9 months follow-up, the patient remains asymptomatic, and has regained full power in his left hand.Download figureDownload PowerPointFigure 1. A, 99% ostial-proximal stenosis of LSA. B, Stenosis crossed via a retrograde approach and dilated with percutaneous transluminal coronary angioplasty balloon. C, Lesion stented with 8×59 Genesis Stent. D, Good antegrade flow in the LSA. LSA indicates left subclavian artery.Download figureDownload PowerPointFigure 2. A, Swelling of left hand, bluish discoloration of the finger tips and palms. B, Resolution of swelling and discoloration of the left hand after reintervention.Download figureDownload PowerPointFigure 3. A, Fluoroscopy of LSA stent revealing complete transaction of the stent at 4 different places. B, Angiogram of LSA revealing pseudoaneurysms in the proximal and distal portion of the stent. LSA indicates left subclavian artery.Download figureDownload PowerPointFigure 4. Sixty-four slice contrast-enhanced computed tomography. A, Multiplanar reformatted image-confirming stent fracture (transaction) at 4 levels. B, Multiplanar reformatted image ruling out stent compression by thoracic outlet structures. C and D, Three-dimensional volume rendered computed tomography images demonstrating the presence of 2 proximal pseudoaneurysms and 1 distal aneurysm.Download figureDownload PowerPointFigure 5. A and B, Angiogram after placement of 8×59 ADVANTA V12 covered stent demonstrating successful exclusion of distal aneurysm and persistent flow in the proximal pseudoaneurysms. C, Placement of coils in the proximal pseudoaneurysms. D, Successful occlusion of proximal pseudoaneurysms.Download figureDownload PowerPointFigure 6. Contrast-enhanced computed tomography after 12 weeks. Three-dimensional volume rendered image demonstrating a patent stent graft and absence of pseudoaneurysms.Subclavian artery angioplasty with or without stenting is a well accepted, less invasive alternative to surgical revascularization for symptomatic proximal subclavian artery stenosis.1 Reports of stent fracture involving the brachiocephalic vessels are rare, because this is a relatively immobile region; thereby, it is protected against the biomechanical stress related to arm movements.2–4 Stent fracture (transection) at multiple levels in the proximal subclavian artery has not been previously reported. Our patient specifically denied any history of trauma or hyperextension injury. The length of the stented segment is a well known risk factor for stent fracture. Another factor could be the continuous mechanical stress within the pulsatile subclavian artery, leading to metal fatigue and stent fracture. A third factor that needs to be considered is the stent design. Periard et al2 reported a similar case of stent transaction within the right brachiocephalic trunk. They postulated that the stainless steel stent could have had mechanical properties that may explain the stent fracture.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/123/20/e602/DC1.Correspondence to Ravindranath Khandenahally Shankarappa, MD, DM, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar 9th Block, BG Road, Bangalore 560069, India. E-mail [email protected]comReferences1. Sixt S, Rastan A, Schwarzwälder U, Bürgelin K, Noory E, Schwarz T, Beschorner U, Frank U, Müller C, Hauk M, Leppanen O, Hauswald K, Brantner R, Nazary T, Neumann FJ, Zeller T. Results after balloon angioplasty or stenting of atherosclerotic subclavian artery obstruction. Catheter Cardiovasc Interv. 2009; 73: 395–403.CrossrefMedlineGoogle Scholar2. Periard D, Haesler E, Hayoz D, Von Segesser LK, Qanadli SD. Rupture and migration of an endovascular stent in the brachiocephalic trunk causing a vertebral steal syndrome. Cardiovasc Intervent Radiol. 2008; 31(suppl 2): S53–S56.CrossrefMedlineGoogle Scholar3. Wada M, Yamamoto M, Shiba M, Tsuji T, Iijima R, Nakajima R, Yoshitama T, Hara H, Hara H, Tsunoda T, Nakamura M. Stent fracture in the left brachiocephalic vein. Cardiovasc Revasc Med. 2007; 8: 103–106.CrossrefMedlineGoogle Scholar4. Phipp LH, Scott DJ, Kessel D, Robertson I. Subclavian stents and stent-grafts: cause for concern?J Endovasc Surg. 1999; 6: 223–226.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Nagato H, Touma M, Ohno N, Yoshikawa E, Yoshizawa K and Fujiwara K (2015) Early Stent Graft Perforation after Endovascular Repair for Pseudoaneurysm That Was Associated with Clavicle Nonunion, Annals of Vascular Diseases, 10.3400/avd.cr.15-00041, 8:3, (268-270), . Oliveira N, Alves G, Rodrigues H, Gonçalves F, Martins J, Morais J, Ferreira M, Castro J and Capitão L (2014) Endovascular treatment of blunt traumatic injuries of the subclavian and axillary arteries, Angiologia e Cirurgia Vascular, 10.1016/j.ancv.2014.07.001, 10:3, (151-158), Online publication date: 1-Sep-2014. Grasso C, Costanzo L and Tamburino C (2013) Subclavian transectional stent fracture and migration to the aortic carrefour: A case description of retrieval by snare system, Catheterization and Cardiovascular Interventions, 10.1002/ccd.25161, 83:6, (1010-1013), Online publication date: 1-May-2014. May 24, 2011Vol 123, Issue 20 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.015834PMID: 21606402 Originally publishedMay 24, 2011 PDF download Advertisement SubjectsComputerized Tomography (CT)Peripheral Vascular Disease